Attachment 2 - OCFS-4553 Bidder Identification Form2.doc

OCFS-4553 (Rev 1/2004)

NEW YORK STATE

OFFICE OF CHILDREN AND FAMILY SERVICES

BIDDER IDENTIFICATION FORM

Firm/Provider:

Address:

City:

State:

Zip:

Authorized Person:

Title:

E-Mail Address:

Telephone:

Fax:

Signature:

Date:

Organization Type

Check one answer for each question This information is required for reporting purposes and to assure equal opportunity to bid.

FORMCHECKBOX

Corporation FORMCHECKBOX Partnership FORMCHECKBOX Proprietorship FORMCHECKBOX Joint Venture

For-Profit

FORMCHECKBOX

Not-For-Profit Provider

FORMCHECKBOX

Municipality

Yes

FORMCHECKBOX

No

MBE *

FORMCHECKBOX

Women-Owned Business*

FORMCHECKBOX

Neither

If MBE Please check one of the following:

FORMCHECKBOX

Black

FORMCHECKBOX

Hispanic

FORMCHECKBOX

Asian/Pacific Islander FORMCHECKBOX American/Alaskan Indian

FORMCHECKBOX

Yes

FORMCHECKBOX

No

Bidders are hereby notified that if their principle place of business is located in a state that penalizes New York vendors, and if the goods or services they offer will be substantially produced or performed outside New York State, the Omnibus Procurement Act of 1994 amendments (Chapter 684, Laws of 1994) require that they be denied placement on bidders mailing lists and contracts for which they would otherwise obtain. Bidders of construction services must be denied the award of a contract if their principle place of business is located in a state that discriminates or imposes a preference against New York State firms jurisdiction.

A current list of states which penalize New York State firms is available from the Procurement Assistance Unit, New York State Empire State Development, Albany, New York 518-292-5250.

Instructions:

A Not for Profit Corporation is defined as an incorporated organization chartered for other than Profit-making activities. Most such organizations are engaged in charitable, educational, or other civic or humanitarian activities although they are not restricted to such activities.

A Small Business Concern is defined as a business which is resident in New York State, Independently owned and operated, not dominant in its field, and employs one hundred or less persons. A Not-For-Profit organization may be considered a Small Business Concern if it meets the preceding criteria.

A Minority Business Enterprise (MBE) is defined as any business which is at least fifty-one percent owned by, or in the case of a publicly owned business, at least fifty-one percent of the stock of which is owned by, United States (U.S.) citizens or permanent resident aliens who are:

a. Black persons having origins in any of the black African racial groups; and/or

b. Persons of Mexican, Puerto Rican, Dominican, Cuban, other Caribbean island, Central South American origin and /or national or community identification, whether of indigenous, Hispanic, Portuguese, French, Dutch, or other descent and regardless of race; and/or

c. Asian and Pacific Islander persons having origins in any of the Far East, Southeast Asia, the Indian subcontinent, or the Pacific Islands; and/or

d. American Indian or Alaskan Native person having origins in any of the origins in any of the original peoples of North America and maintaining identifiable tribal affiliations through membership and participation or community identification; and such ownership interest is real substantial and continuing. The minority ownership must have and exercise the authority to independently control the business decisions of the entity.

A Minority Community Based Organization (MCBO) is defined as a Not-For-Profit, local human service organization that has its origins in the geographic area comprised of one or more neighborhoods that it serves. A representative MCBO is therefore keenly aware of community needs as well as local resources to meet those needs. Generally, the governing bodies and personnel of community-based organizations reflect the racial, ethnic and cultural make-up of the community being serviced. A MCBO is characterized by majority representation of American Indians, Asian Americans, Blacks and/or Hispanics in both policy formulation and decision making regarding management, service delivery and staffing reflective of the area that it serves.

A Woman-owned Business Enterprise (WBE) is defined as any business enterprise which is at least fifty-one percent owned by, or in the case of publicly owned business, at least fifty-one percent of the stock of which is owned by citizens or permanent aliens who are woman. Such ownership interest must be real, substantial and continuing. The Women-Owned Ownership must have and exercise the authority to independently control the business decisions of the entity. (To meet the definition of an MBE or WBE, a Non-Profit organization must be controlled by a Board of Directors consisting of at least fifty-one percent minority individuals or women, respectively.)

NEW YORK STATE CERTIFIED MINORITY or WOMAN OWNED BUSINESS – Limited to For-Profit organizations which have been certified by the New York State Empire State Development as meeting the criteria for a Minority or Women Owned Business. Contact the New York State Empire State Development, Division of Minority and Women’s business Development at 212-803-2414 or 518-292-5250 for certification assistance.